Acknowledgments

I sincerely pray Allah for faith granting me the will and strength to perform this work .
I would like to express my respect to Prof. Nazar G. Al-Talabani , Dean of College of Dentistry , University of Baghdad .
I would like to express my sincere and deep appreciation to my supervisor Prof. Raja K. Kummoona due to his wise , objective pieces of advices , enthusiastic encouragement in every step of this work .
I would like to thank Assist. Prof. Dr. Anwar A. Al-Saeed , the chairman of oral and Maxillo-facial Surgery Dept., and also my great appreciation to all my teachers for their support .
I would like to thank the head of X-ray Dept. Dr. Khadom and Dr. Thikraa in (US) and Dr. Fawaz A. Rassam in (MRI) and all his staff specially X-ray tech. Mohsin A. Al-Aubodi and Abdulah Thaher Al-Shimari for their increscent help which allow me to cop with all problems and obstacles .
Many thanks for senior , Juniors staff of oral and Maxillofacial Surgery Dept. in Al-Kadhemia Teaching Hospital for their sincere cooperation .

Abstract

This study was carried on (46) patients (46 joints) with TMJ disorders , all the patients have pain and many of them have clicking , cripetation , and / or locking. Those patients were examined in the consultation clinic of oral maxillofacial surgery department in Al-Kadhemia Teaching Hospital from April – 2004 to November 2004 .
All the patients were examined by means of MRI and ultrasonography (US), all (46) patients with symptoms of disk internal derangement (I.D.) the results of (US) were compared with these of volunteer (18 joints) without symptoms (D.I.D.) .
Analysis of (64) joints showed clicking was detected in 22 patients , poping in 4 patients , reciprocal clicking only in 2 patients , no TMJ sound in 34 patients , 32 patients have pain in the muscles of mastication , 32 patients have no pain and 36 patients had limitation of mouth opening .
MRI & US were used for imaging and diagnosis of D.I.D. of TMJ. US provides an image of the TMJ in the coronal (plane in which the disk becomes more obvious in the open – mouth position in both normal and displaced joints .
US may help in the confirmation of normal disk position in subjects presenting symptoms of normal disk position . In subjects presenting symptoms of D.I.D. TMJ Examiner experience is very important to use of US . With an experienced radiologist , images obtained by US will be interpreted more accurately . US will also help in the identification of disk position in subject with signs and symptoms of internal derangement of TMJ .
The results of our study showed perfect agreement between MRI and US in all the cases , and this considered a big advantage since US , is more available in our hospitals than MRI, more simple , easily done than MRI and also more accepted by the patients than MRI , so it can be used as an ulternative method to MRI in diagnosis of D.I.D. of TMJ .

List of Contents

No. Subject Page
Acknowledgments I
Abstract II
List of contents III
List of Abbreviation VII
List of figure IIX
List of tables XI
Chapter One : Introduction and Aim of the study
1.1 Introduction 1
1.2 Aim of the study 3
Chapter Two : Review of literature
2.1 Anatomy of Temporomandibular joint 4
2.1.1 Characteristic features 4
2.1.2 Development of temporandibular joint 5
2.1.3 Theories of growth of mandible 6
2.1.4 Anatomy of TMJ 7
2.1.4.1 Osseous component 7
2.1.4.2 Soft tissue component 9
2.1.5 Blood supply of TMJ 18
2.1.6 Nerve supply of TMJ 20
2.1.7 Movement 20
2.1.8 Important relations of the TMJ 21
2.2 Temporomandibular disorders 21
2.2.1 Developmental disorders 22
2.2.1.1 Condylar agenesis 23
2.2.1.2 Condylar hyoplasia 23

No. Subject Page

2.2.1.3 Condylar hyperplasia 24
2.2 Traumatic disorders 25
2.2.1 Fracture of the condyle 25
2.2.1.1 First classification 25
2.2.1.2 Second classification 26
2.3 Subluxation 27
2.3.3 Functional 28
2.3.3.1 Causes of Ankylosis 28
2.3.3.1.1 Age of the patient 29
2.3.3.1.2 Site and type of the fracture 29
2.3.3.1.3 Damage to meniscus 29
2.3.3.1.4 Duration of immobilization 29
2.3.3.2 Classification of Ankylosis 30
2.3.4 Degenerative Joint diseases 30
2.3.4.1 Rheumatoid arthritis of TMJ 30
2.3.4.2 Osteoarthritis 31
2.3.4.3 Clinical staging of internal derangement 32
2.3.4.4 Etiology of internal derangements 32
2.3.4.5 Disk displacement 34
2.3.4.6 Etiology of disc displacement 35
2.3.4.7 Functional classification of the disk displacement 35
2.3.4.8 Infection of the TMJ 36
2.3.4.9 Tumor (Neoplasm) of the condyle 36
2.3.4.9.1 Benign Tumors 37
2.3.4.9.2 Malignant tumors 37

No. Subject Page

2.3.4.9.2.1 Primary malignancies 37
2.3.4.9.2.2 Secondary Malignancies 37
2.4 Imaging of TMJ 37
2.4.1 Plain film Radiography 37
2.4.2 Arthrography 40
2.4.3 Computerized tomography 41
2.4.4 Magnetic resonance imaging 41
2.4.5 TMJ Sonography 42
2.4.5.1 Historical development of diagnostic (US) 42
2.4.5.2 Principle of Ultrasound 42
2.4.5.3 Types of ultrasound display 43
2.4.5.4 Normal findings of TMJ by (US) 44
2.4.5.5 Abnormal findings of TMJ by (US) 45
2.4.5.5.1 Internal derangement 45
2.5 Principles of MRI 46
2.5.1 MRI of Normal TMJ 48
2.5.2 MRI characteristics of disk displacement 51
Chapter Three : Materials and Methods 56

3.1 Materials 56
3.1.1 Patients 56
3.1.2 Patients selection 56
3.1.3 Material and equipment 57
3.1.3.1 MRI machine 57
3.1.3.2 Ultrasound machine 59
3.1.3.3 Coupling Agent 62

No. Subject Page

3.1.3.4 Ultrasound transducer 62
3.2 Methods 65
3.2.1 Patients case sheet 63
3.2.2 Clinical assessment 65
4 Chapter Four : Results 67
5 Chapter Five : Discussion 79
5.1 Normal US findings 79
5.2 Ant. disk displacement 79

6 Chapter Six : Conclusions and suggestions 83

6.1 Conclusions 83
6.2 Suggestions 84
References 85

List of Abbreviation

Abbreviation Details
CT Computerized Tomography
MHz Megahertz
MRI Magnetic Resonance Image
TMJ Temporomandibular Joint
US Ultrasound
RW Displacement of TMJ with reduction
RWO Displacement of TMJ without reduction
LPM Lateral ptrygoid Muscle
MPM Medial Ptrygoid Muscle
LPP Lateral Ptrygoid plate
PAV Postero anterior view
APV Antero Posterior view
CT Computerized Tomography
TMJDs Temro Modibular joint disorders
ID Internal derangement

List of Figures
No. Title Page
(2-1) The TMJ is formed by the mandibular condyle occupying a hallow in the temporal bone (the mandibular fossa) [Burket’s O. M. 10th ed.] 8
(2-2) The TMJ is a ginglymo arthrodial joint that is capable of hinge type movements and glinding movements . The articular disk has ligamentous attachments to the mandibular fossa and condyle , separate it into 2 compartment (Burket’s , O. Med.) 10
(2-3) The capsularlig is a thin inelastic fibrous connective tissue envelope . The TMJ is lateral to the capsule (Burket’s , O. Med.) 14
(2-4) The masseter and medial pterygoid muscles have their insertions inf-border of mand. Angle (Burket’s , O. Med.) 16
(2-5) The digastric muscle is a paired muscle with two bellies (Burket’s , O. Med.) 17
(2-6) The lateral pterygoid muscle is the main protrusive and opening of the mandible (Burket’s , O. Med.) 18
(2-7) Branches of the aurticulotemporal nerve supply sensony innervation of TMJ (Burket’s , O. Med. 10th edition) 19
(2-8) Level of condylar Fracture A. Intra capsular Fracture B. Condylar Faracture C. Sub-condylar Fracture (Fonseca , 1997)
26
(2-9) Relationship condylar head to the glenoid fossa (Quinn 1998) 26

No. Title Page
(2-10) Schematic representation of fanctional disk displacement . 47
(2-11) Cryosection sagittal view of classed TMJ 50
(2-12) MRI for TMJ shows (RW) disk displacement with reduction 52
(2-13) MRI of TMJ showing disk displacement without reduction RWO 53
(3-1) MRI machine / 1-5 tesla closed system 57
(3-2) Patient in supine position inside of MRI unit 58
(3-3) Siemens – sonoline Germany 59
(3-4) Linear probe 10.0 L25 59
(3-5) Placement of the US / probe against a patients face
A. (open – mouth ) B. (closed – mouth) 60
(3-6) Normal US image for TMJ open and closed 60
(3-7A) US showing displacement with reduction (RW) 61
(3-7B) US showing disc – displacement without reduction 61
(3-8) A. Using millimeter vernier for measuring maximum mouth opening.
B. Stethoscopic examination of TMJ clicking 65
(3-9) A. Unassisted mandibular opening
B. Assisted mouth opening 65
(3-10) Assisted TMJ pain on palpation of lateral aspect of condyle 66
(4-1) Distribution of samples by signs & symptoms 70
(4-2) Fig(4-2) MRI-US cross tabulation 71
(4-3) Relation between age of the patients and range of age 72
(4-4) Relation between female No. of patients and range of age 73

No. Title Page
(4-5) Relation between male No. of patients and range of age 74
(4-6) Sagittal view MRI of TMJ Ant. display cement of disc without reduction 75
(4-7) A. Normal US findings
B. Normal MRI findings 76
(4-8) A. US disc – displacement with reduction
B. MRI of disc displacement with reduction 77
(4-9) A. US of disc displacement without reduction
B. MRI of disc displacement without reduction 78

List of Figures

No. Title Page
(3-9) Assessment of mandibular opening / A. unassisted
B. assisted 66
(3-10) Assissment of TMJ pain on palpation of lateral aspect of condyle 66
(4-1) Distribution of samples by signs and symptoms 71
(4-2) MRI US crosstabulation 72
(4-3) Sagittal view MRI of TMJ Ant. displacement of disc without reduction 76
(4-4) A. Normal US findins / B. Normal MRI findings 77
(4-5) A. US of disc displacement with reduction
B. MRI of disc displacement with reduction 78
(4-6) A. US of disc displacement without reduction
B. MRI of disc displacement without reduction 69
(4-7) Relationship between age of the patients and range of age 73
(4-8) Relationship between female no. of the patients and range of age 74
(4-9) Relationship between male no. of the patients and range of age 75

List of Tables

No. Title Page
(2-1) Wilkes staging of internal derangement 27
(2-2) Relative brightness of body tissue 44
(4-1) Clinical findings 62
(4-2) MRI and US for TMJ 63
(4-3) Distribution of sample by signs and symptoms 64
(4-4) K-measuerment of agreement 65
(4-5) Anova table of agreement 70